Fillable Printable De 2325

De 2325

EMPLOYER’S ELECTION TO COVER A MULTI-STATE WORKER UNDE R THE

CALIFORNIA UNEMPLOYME NT INSURANCE CODE

Use this fo rm to request coverage for unempl o yment insurance under the laws of Califor nia when an

employee works in two or more states. This election, if approved, may become effe ctive as of the first day of

either the calendar quarter in which it is submitted, or a n y subsequent quarter as designated. Complete both

sides of this form and return to:

Employment Development Department

Central Operations – MIC 94

P.O. Box 826880

Sacramento, CA 94280-0001

Questions may be directed to the above address, or call (888) 745-3886.

Business Name: EDD Account No.

Business Address:

Employee Name: Employee SSN:

Employee Address:

Please refer to Information Sheet: Multi-State Employment (DE 231D) for an explanation of

localization, base of operations, place of direction and control, and residence of employee. This will

assist you in answering the following questions.

1. Are the employee’s services localized? No Yes If yes, in which state?

If the services are localized in one state, the wages of your employee should be re ported to that state, and

an election is not available.

2. Where is the employee’s base of operations?

3. From which state does the employee receive his direction and control?

4. What is the employee’s state of residence?

5. What is the nature of the business?

6. List all of the states in which the employer has a place of business:

7. What type of services are performed by the above named employee?

8. List all of the states in which services are performed by the above named employee:

9. What is the reason for requesting coverage in California?

10. Indicate the date that you want this election to become effective:

DE 2325 Rev. 16 (3-10) (INTERNET) Page 1 of 2

EMPLOYEE AUTHO RIZATION

I the undersigned, concur with my employer’s request that my services for the purposes of unemployment

and disability insurance are deemed to be performed entirely within the State of California and hereby

consent to such determination. This coverage is to remain in effect until such time as the conditions of my

employment with respect to where my services are performed change to the extent that I no longer

customarily perform services in more than one state, or the agreement is otherwise terminated.

Signature: Date:

EMPLO YER AUT HORIZATIO N

The employer hereby agrees to comply with any requirements applicable to this election under the

California Unemployment Insurance Code and understands that any change in the conditions of

employment that would invalidate this agreement must be immediately reported to this department and the

agreement terminated. Except as provided in the previous sentence, each approved election shall remain

in effect through the close of the calendar year in which it is submitted, and thereafter until the close of the

calendar quarter in which the electing unit gives written notice of its termination to all affected agencies.

The employer also agrees to provide a copy of this election to the employee promptly after its approval.

Authorized Agent: Phone Number:

(Please Print)

Title:

Signature: Date:

APPROVAL REQ UIRED BY STATE OF CALI FORNIA AND S TAT E OF JURISDICTION

APPROVAL BY STAT E OF JURISDICTION

The foregoing election is approved.

Approval by state of

Signature: Date:

Title: Agency:

APPROVAL BY STAT E OF CALIFORNI A

The foregoing election is hereby approved as submitted. Coverage under this election is effective as of

Signature: Date:

Title: Agency: Employment Development Department

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